AS a young MD in 1984 in the field of endocrinology (the study of hormones), the first task assigned to me at the All India Institute of Medical Sciences (AIIMS) was to carry out field studies on iodine deficiency disorders (IDD). This meant travelling to remote parts of eastern Uttar Pradesh, Bihar and Assam to perform surveys, collect blood samples and palpate (examine) necks for the presence of goitre. What I saw was much more than I expected.

I surveyed village after village where children were stunted, with less than normal cognitive ability, unable to carry out their day-to-day activities. Soon, we realized that this was ‘cretinism’, a condition that occurs due to lack of iodine during pregnancy and infancy. Along with it came the realization that simply adding iodine to common salt, an inexpensive process referred to as fortification, could save the masses from such devastation.

The Indian government, based on data generated by the AIIMS team, decided to make salt iodization universal in 1986¹ and finally mandatory in 2005, after much back and forth. This is one of independent India’s most remarkable success stories in the field of nutrition. It has led to the near elimination of cretinism and goitre, which once affected millions of Indians. Strong evidence-based policies and effective mass media awareness made the accomplishment of this mission possible.

Iodine, an essential mineral commonly found in seafood, is part of a group of vitamins and minerals, also known as micronutrients, which are critical for optimal health throughout life. Micronutrients – including iron, zinc and vitamins A and D – are required only in small amounts but are essential for our bodies to produce enzymes, hormones and other substances necessary for proper growth and development. On the other hand, proteins, carbohydrates and fats are characterized as macronutrients. The World Health Organization (WHO)² refers to micronutrients as ‘magic wands’, tiny amounts of which help our bodies to function healthily.

 

While we have made appreciable progress in addressing ailments occurring due to iodine deficiency, several other micronutrient deficiencies continue to be rampant among both urban and rural populations in India. It is estimated that one-third of the two billion micronutrient-deficient individuals globally are Indians.³

While micronutrient malnutrition can affect all age groups, young children and women of reproductive age tend to be more vulnerable to its impact. National Family Health Survey (NFHS-4, 2015-16) data reveals that more than 50% of women and over 58% of children suffer from anemia (iron deficiency)⁴ in our country. A study⁵ on the global burden of anemia in 2013 found that one in three Indians have anemia. At 447 million cases, this number makes up a quarter of cases worldwide. The same study also found that iron deficiency anemia was the dominant cause of anemia globally and in most populations.⁶

The recent Comprehensive National Nutrition Survey (CNNS) 2019 further reveals that 19% of pre-school children and 32% of adolescents have zinc deficiency,⁷ and 23% of pre-school children and 37% of adolescents have folate deficiency. The prevalence of vitamin B12 and vitamin A deficiencies for pre-school children and adolescents are between 14% and 31%.

 

During the 1990s, when I was teaching at the Sanjay Gandhi PGIMS in Lucknow, I was asked to examine a young, well-to-do, urban woman, confined to a wheelchair, with profound muscle weakness and bone pains. She had travelled far and wide in search of a diagnosis and had seen the best experts in neurology and orthopaedics, without avail. After evaluation, we realized that she was suffering from extreme vitamin D deficiency, also called osteomalacia.

Unfortunately, hers was not a rare condition. Over the years, vitamin D deficiency has emerged as a silent public health emergency. It is prevalent in all age groups. The prevalence of vitamin D deficiency in India ranges from 40% to 99%, with most studies reporting a prevalence of 70%-100%.⁸ According to the CNNS, over14% of pre-school children, 18% of school age children and 24% of adolescents are deficient in vitamin D.⁹

Vitamin D, which is not present in significant amounts in food, is critical for absorbing dietary calcium from the gut, and plays a key role in our bone and muscle health. Its deficiency can lead to muscle and bone weakness in children and adults, resulting in rickets in childhood and osteomalacia in adults. Inadequate vitamin D can also make individuals more prone to infections, especially respiratory viral infections. Most recently, it has been proposed that replenishing vitamin D in deficient individuals can reduce the risk or severity of Covid-19 infection.¹¹

 

Unlike hunger and malnutrition, the impact of which is more obvious and visible, micronutrient deficiencies can often go unnoticed until they either reach a more severe form, or until large sections of the population are impacted by the less obvious ‘invisible’; effects.¹² It is because of their stealthy nature that micronutrient deficiencies are often called ‘hidden hunger’. Such deficiencies can have a devastating impact on overall physical and cognitive development and may result in anemia, attenuated child growth, poor productivity, and even death if left unaddressed.¹³

The consequences can be especially catastrophic for vulnerable groups, increasing the risk of low birth weight, birth defects, stillbirth, and even death. While micronutrient deficiencies could occur in anyone among socioeconomically marginalized populations, these deficiencies often contribute to a vicious cycle of malnutrition, underdevelopment and poverty. According to the World Bank, India loses over USD12 billion in GDP to vitamin and mineral deficiencies.¹⁴

Despite governmental efforts, micronutrient malnutrition remains unchecked in India. There are several reasons for this. First is the low awareness around micronutrients and the importance of minerals such as zinc and iodine in diets. For example, not many know that naturally occurring common salt does not contain iodine. Another obvious reason is that much of the population just doesn’t have enough to eat. India ranked 102 among 107 countries on the Global Hunger Index-2019. But even for people who do have enough, the staples consumed are less nutrient-rich than before. This is partly due to the conscious choice to cultivate high-yielding, rather than highly nutritious, crops.¹⁵

 

Changing urban diets also contribute to rising micronutrient deficiencies among people who have enough to eat. Foods high in carbohydrates (especially simple sugars) and fats, but lacking in vital vitamins and minerals, are easily available at fast food joints at every corner. The consumption of such ‘junk food’ is increasing among educated and wealthier households. Yet, traditional diets aren’t necessarily the solution. Indian vegetarian diets are often less nutrient-rich than those from animal sources, particularly with regard to proteins and vitamins like B12. Our ghar ka khana can also fall short of nutrients due to over-processing and over-cooking.

Food fortification, dietary diversification, supplementation programmes and global public health and disease control measures are defined strategies to deal with micronutrient malnutrition.¹⁶ Fortification of food with micronutrients is a time-tested strategy that can reach wider, vulnerable populations through existing food delivery systems. Food fortification is the practice of adding an approved premix of vitamins and minerals (essential micronutrients) in widely consumed foods and condiments with the aim of improving its nutritional quality and providing a public health benefit with minimal risk to health.¹⁷ According to WHO, fortification is a widely-recognized and highly cost-effective strategy for increasing nutrient intake, one that doesn’t require change in eating behaviour or substantial government budgets.¹⁸

 

Fortification has been used safely and effectively to prevent vitamin and mineral deficiencies for more than a century. The United States and Switzerland have fortified foods since the 1920s, when iodine was first added to salt. Since the 1940s, wheat and other flours have been fortified in numerous countries, both to replace micronutrients lost in processing and as a public health intervention.

Fortification is easy to scale, especially when existing food supplies and limited access fail to provide adequate levels of the required nutrients in the diet. A report by the Food Safety and Standards Authority of India (FSSAI), which quotes the World Bank, states that no other technology available today can offer such an opportunity to improve lives and accelerate development at such a low cost and in such a short time.¹⁹

In 2008, the Copenhagen Consensus, a panel of Nobel laureates, determined that providing micronutrients in the form of iodized salt, vitamin A capsules and iron-fortified flour for 80% of the world’s malnourished would cost USD 347 million a year.²⁰ Gains in productivity and savings to a nation’s healthcare system are many times this cost, as the investment would yield USD 5 billion from avoided deaths, improved earnings and reduced healthcare spending.²¹ A global report in 2009 showed that every dollar spent on salt iodization and flour fortification would result in benefits of more than USD 10.²²

 

In India, the fortification of vanaspati was made compulsory as far back as 1953. The vitamin A supplementation programme for children under five years of age has been running for more than a decade. However, despite that, only 60% of children under-5 had received a dose of vitamin A in the six months preceding NFHS-4. Further, the National Nutrition Monitoring Bureau’s technical report for 2012 revealed that the overall mean vitamin A intake through food was a measly 21% of the recommended dietary allowance (RDA).²³ This clearly shows that all age groups in India suffer from vitamin A deficiency. There is no vitamin A supplementation programme yet to cover children above five years, pregnant women, post-partum women and adults.

 

Similarly, widespread vitamin D deficiency has been reported in people of all ages, in both sexes, residing in rural and urban India. Around 80% of the urban population has been shown to have sub-optimal serum vitamin D levels.²⁴ Moreover, there is no supplementation programme for vitamin D in India, and voluntary fortification of milk and edible oil has been initiated only recently.

FSSAI has played a pioneering role in creating an enabling environment for the uptake of fortified food and staples across the country, placing food fortification firmly on the national agenda.²⁵ In late-2016, they notified the standards of fortification for wheat, oil, milk, flours, double fortified salt (fortified with iodine and iron) and rice in the Gazette of India, thereby creating a rallying point for industry to voluntarily adopt fortification. To ensure consumption of fortified foods in adequate amounts by people, it is important to raise mass awareness on this issue.

Through national-level campaigns such as Eat Right India and engagement with influential voices, FSSAI has been working to raise awareness on the benefits of consuming fortified staples. In a game changing policy, FSSAI introduced the F+ logo, making it necessary for manufacturers to brand products fortified with micronutrients with this logo for easier identification and awareness.

 

Fortified staples have already been incorporated into midday meals and the Integrated Child Development Services (ICDS) in India. In another welcome move, well known dairy chains in India have initiated the fortification of milk. The ministry of women and child development (MWCD) and the ministry of human resource development (MHRD) have issued advisories to all states for inclusion of double fortified salt and fortified wheat flour and oil in their programmes. According to FSSAI, consumption of fortified foods through these two schemes, along with diet diversification, will help meet 30%-50% of the RDA.²⁶ The NITI Aayog is also seeking creation of a roadmap from the department of food and public distribution for taking the Rice Fortification Pilot Scheme pan-India.

Achieving the goal of a malnutrition-free India by 2022 calls for a scaling up of efforts like fortification. As was the case with the iodization of common salt, the time has come for all stakeholders to combine for a major policy push towards mandatory fortification. Fortification of edible oils offers the most feasible and cost-effective intervention to address vitamin A and D deficiencies, as India has a fairly high rate of consumption of edible oils (2-18 kg/per person/per annum),²⁷ while the cost of fortification is around 10 paise per litre/kg of oil.3 Considering that the future consumption of oil is expected to grow by 3% annually, a shift towards mandatory fortification of all packaged edible oil will ensure that its benefits reach almost 800 million people.²⁸

There are, however, challenges associated with every fortification programme. These include accurate assessment of micronutrient intake (since multiple food items are being fortified with the same nutrients), strict regulation in terms of quality and quantity of nutrients added, and a constant monitoring and surveillance system. Long-term monitoring of the clinical impact of fortification on the population is vital. It’s only when the health parameters start changing – for example, reduction in prevalence of anemia – that we can consider a fortification programme truly successful.

Food fortification is the global norm, with no detrimental impacts upon the final food product or business profitability and sales. However, while we strive for mandatory fortification of edible oil and milk with vitamins A and D, ensuring widespread access throughout the country may require diverse delivery mechanisms, for which it may be prudent to involve the private sector. India already has an impressive record with iodine-fortified salt, which has virtually eradicated goitre and cretinism. Similar efforts to promote systematic scale-up of fortification of staples and foods can result in a marked reduction in the prevalence of micronutrient deficiencies in India.

 

Footnotes:

1. J. Rah et al., ‘Reaching the Poor with Adequately Iodized Salt Through the Supplementary Nutrition Programme and Midday Meal Scheme in Madhya Pradesh’, Bulletin of the World Health Organization 91, 2013. http://dx.doi.org/10.2471/BLT.12.110833

2. World Health Organization, ‘Nutrition’. https://www.who.int/nutrition/topics/micronutrients/en/

3. P. Kotecha, ‘Micronutrient Malnutrition in India: Let Us Say "No" to It Now’, Indian Journal of Community Medicine 33(1), 2008. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782240/

4. Children from 5 months to 59 months.

5. N.J. Kassebaum, ‘The Global Burden of Anemia’, Hematol Oncol ClinN Am 30, 2016, pp. 247-308. http://dx.doi.org/10.1016/j.hoc.2015.11.002

6. Ibid.

7. Ministry of Health and Family Welfare, Government of India, UNICEF and Population Council, Comprehensive National Nutrition Survey (CNNS) National Report, New Delhi, 2019. https://nhm.gov.in/WriteRead-Data/l892s/1405796031571201348.pdf

8. P. Aparna et al., ‘Vitamin D Deficiency in India’, Journal of Family Medicine and Primary Care 7(2), 2018. https://doi.org/10.4103/jfmpc.jfmpc_78_18

9. Comprehensive National Nutrition Survey (CNNS) National Report, 2019.

10. United Nation’s Children Fund, ‘Vitamin A’, 2019. https://data.unicef.org/topic/nutrition/vitamin-a-deficiency/

11. W. Grant et al., ‘Evidence That Vitamin D Supplementation Could Reduce Risk of Influenza and Covid-19 Infections and Deaths’, Nutrients 12(4), 2020.

12. Welthungerhilfe, International Food Policy Research Institute and Concern Worldwide, Global Hunger Index 2014, The Challenge of Hidden Hunger. https://www.ifpri.org/sites/default/files/ghi/2014/feature_1818.html

13. S. Swaminathan, B. Edward and A. Kurpad, ‘Micronutrient Deficiency and Cognitive and Physical Performance in Indian Children’, European Journal of Clinical Nutrition 67, 2013. https://www.nature.com/articles/ejcn201314

14. World Bank, ‘India Has Potential to Dramatically Reduce Stunting in Children, Says New World Bank Report’, press release, 2014. https://www.worldbank.org/en/news/press-release/2014/11/13/india-potential-to-dramatically-reduce-stunting-in-children-new-world-bank-report

15. R. DeFries et al., ‘Metrics for Land-scarce Agriculture’, Science 349(6245), 2015.

16. Food and Agriculture Organization and International Life Sciences Institute, Preventing Micronutrient Malnutrition: A Guide to Food-based Approaches – Why Policy Makers Should Give Priority to Food-based Strategies, 1997. http://www.fao.org/docrep/x0245e/x0245e01.htm

17. L. Allen et al. (eds.), Guidelines on Food Fortification with Micronutrients. World Health Organization and Food and Agriculture Organization (UN), 2006. http://www.who.int/nutrition/publications/guide_food_fortification_micronutrients.pdf

18. World Health Organization, ‘Food Fortification Q&A’, 2018. https://www.who.int/vietnam/news/feature-stories/detail/food-fortification-q-a

19. Food Safety and Standards Authority of India, Journey of Food Fortification: Fighting Malnutrition, Improving Lives. http://ffinetwork.org/regional_activity/images/India_Journey.pdf

20. Food Fortification Resource Centre, Large Scale Food Fortification in India: The Journey So Far and Road Ahead. Food Safety and Standards Authority of India, 2017. http://45.115.99.201/fssai/upload/knowledge_hub/5a7d880c7b66dLarge_scale_Food_Fortification.pdf

21. Food Fortification Resource Centre, 2017.

22. FFI, GAIN, MI, USAID, World Bank, UNICEF, Investing in the Future: A United Call to Action on Vitamin and Mineral Deficiencies, Global Report 2009. https://www. who.int/vmnis/publications/investing_in_the_future.pdf?ua=1.

23. National Institute of Nutrition, Diet and Nutritional Status of Rural Population: Prevalence of Hypertension & Diabetes Among Adults and Infant & Young Child Feeding Practices, 2012. http://maternalnutritionsouthasia.com/wp-content/uploads/NNMB_Third_Repeat_Rural_Survey_Technicl_Report_26.pdf

24. V. Varshney, ‘Vitamin D Complex’, Down To Earth, 11 June 2015. https://www.down-toearth.org.in/coverage/vitamin-d-complex-40446

25. New standards now provide a minimum and a maximum range for fortification of staples like wheat flour (atta), maida, rice, salt, vegetable oil and milk.

26. Food Fortification Resource Centre, Food Fortification in India: Status and Road Ahead, Food Safety and Standards Authority of India, 2018. https://ffrc.fssai.gov.in/assets/news/file/food-fortification-in-india-status-road-ahead-further-scale-up.pdf

27. Food Fortification Resource Centre, 2017.

28. Press Trust of India, ‘India’s Edible Oil Consumption to Exceed 34 Million Tonnes by 2030: Report’, the Hindu BusinessLine, 25 June 2018. https://www.thehindubusinessline.com/economy/agri-business/indias-edible-oil-consumption-to-exceed-34-million-tonnes-by-2030-report/article24254536.ece